Gateways activities, like any active sport, involve a certain risk of injury. In the unlikely event that a participant is injured, Gateways would like to take the appropriate actions. Please fill out this form completely and legibly. The information on this form is required for admission into any US hospital. The information will be held in strict confidence.
Participant Name (please print): _________________________________________
Parent or Legal Guardian (please print): ___________________________________(if under 18 years of age)
Does the participant have any medical conditions that Gateways needs to know about to ensure the participants safety in the event medical treatment is needed? If yes, please list. Include allergies (including bee stings), adverse reactions to any medical drugs, asthma, diabetes, fainting spells, heart trouble, convulsions, bleeding disorders, or any other problems.
No _____ Yes _____(please explain)
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
This health history is correct as far as I know, and the person herein has permission to engage in all prescribed activities. In the event I, or the person listed below, cannot be reached in an emergency, I hereby give permission to have 1) Gateways NERO members render first aid, and 2) any physician hospitalize, secure proper anesthesia, or order injection for (participant's name).
____________________________________ (print name)
Signature of Parent or Guardian (if under 18), or Participant (if 18 or older)
_________________________________________(Signature) Date:_______________
Parent or Guardian Phone Number: (___) ____________
In case of emergency contact (or enter NONE):
Name:____________________________________ Relationship:_________________________
Address:_______________________________________ Phone:(____)___________________
______________________________________________
Medical Insurance Information (Plan or Policy Number): ________________________________
Family Doctor:__________________________________ Phone:(____)___________________